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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ,W) owe, GP& - 3� S�U�7 I vo <br /> OWNER I OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Vet Number Direction Street Name City Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) !' Y P.� w A� <br /> q� 5�OV Street Number Street Name �'" <br /> CITY C�d�T ,� h STATE e ZIP <br /> C1 J <br /> PHONE#1 L T• APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUE:STOR ) CHECK If BILLING AuDRESS1:3 <br /> BUSINESS NAME yV� y� 1 G�7° PHONE# A / ( I,O EXT. <br /> HOME Or MAILING ADDRESSfI 99 C/ FAX# <br /> o Wl (/'y7'1� thJ ( ) <br /> y CITY �r rri rfGtn ) T E zip i' <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all Site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly Charges associated with this project or <br /> activity will be billed to me or my business as identified on this form. <br /> also certify that f have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. j <br /> APPLICANT'S SIGNATURE: DATE: _1 <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> IfAPPLICAN7 is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results,geotechnical data and/or environmentallsite assess Ianon <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time it IS � V <br /> my representative. I <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: SAN 1IEWWR�UIQ O'dU/V71-� <br /> I p-�cry dppE �Nr <br /> ACCEPTED BY-. EMPLOYEE#: DATE: <br /> ASSIGNED TO: S�J EMPLOYEE M DATE. <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: Z <br /> Fee Amount: Amount Paid /5;-?,QD Payment Date CA// <br /> Payment Type Invoice# Check# /Received dy: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />